How can we improve mental health screening?

Medical care and understanding have changed since separation of physical and mental health made much sense. We know now that mental state and internal physiology influence one another and that social factors affect disease risk more powerfully than genetic ones. Still, as a health care system, we perpetuate a culture of division, and limit our capacity to help people because of our inability to categorize them neatly.

There are so many with unmet mental health needs in our communities: The few with severe illness we can see and get to and sometimes fix, the many with less severe conditions we don’t know always how to reach. There’s the complex relationship between homelessness, mental illness, drug abuse, and crime. We invest in huge prison populations and now in treatment programs too, but less than ever on affecting the pathologies at the root of those problems. We are only as good as the care we take of our most vulnerable, and we are failing those least capable of calling attention to the fact.

It’s understood that prevention is a cost-effective strategy for dealing with many types of illness, but it’s seldom discussed in the context of mental health. Like the annual physical or six-month cleaning at the dentist, there must be some value in a periodic screening or at least some amount of contact with a mental health professional for those at greatest risk. A worsening physical illness — back pain, pneumonia — becomes more difficult for a patient to ignore. A worsening mental illness can leave patients less likely or able to seek out help, which is reason to treat it differently than most disease.

When we rely on patients to initiate contact with the health care system, access is a problem. So is stigma: If care is available, fear of a label motivates some patients to forego treatment. Even when providers see that mental illness contributes to a patient’s condition, it’s more easily ignored than a physical injury of similar magnitude, and cultural views of mental illness are part of this.

Similarly, although it’s ubiquitious to and sometimes celebrated in our culture, stress is a mental health topic. Like anything, stress can be constructive if we deal with it well or harmful if we cope with it poorly. It can provoke real physical symptoms in otherwise healthy people.

Chronic, unmanaged stress weakens our immune systems, which means some amount of disease can be prevented through its treatment. Stress can stimulate accumulation of body fat by keeping cortisol high, and interventions like mindfulness-based stress reduction can help to manage the stress hormone. We prescribe drugs for depression which change the way neurotransmitters behave in the brain, but exercise also can influence the way those chemicals act. If we’re seriously dedicated to helping people achieve better health, we shouldn’t treat meaningful lifestyle changes as something ancillary to other medical care.

It’s not always easy to discuss mental health topics or to find the right services for our patients, but it is something that we can improve without major change. Patients come into our system, and we treat problems which are sometimes secondary to those with which they need the most help, because that’s how health care is made to work right now. We operate in narrow partitions from one another, and when patients are in our areas of focus, we discuss only things we know how to help solve. The result is sometimes unclear ownership of a problem: a real barrier created by artificial divisions. It’s difficult enough to get these patients in contact with some kind of service at the right time, and we shouldn’t be making it more difficult to get to the right type of care.

Outreach and screening can become high-value focuses: They can help us get to patients before they are very sick, they can enable us to treat patients more effectively (and cheaply), they can reduce the volume of patients seeking care in the wrong places (like the ER). Under an accountable care organization model, screening becomes an obvious choice for taking better care of people at lower cost. Under a fee-for-service model, we don’t have the support for outreach, and it becomes harder to justify and approve. The onus to capture cost-effectiveness on a worksheet, another artificial problem, creates a real barrier to important work.

John Corsino is a physical therapist who blogs at his self-titled site, Health Philosophy.

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How can we improve mental health screening? 3 comments

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Jason Seidel

There are a few ultra-brief mental health screening tools that are ‘on the market’ currently. Several are freely licensed for individual providers, and take only a few seconds to administer. They are also normed for adults or both for adults and children, reliable, and validated against much longer ‘gold-standard’ MH measures. These are global “subjective well-being” measures rather than symptom-focused measures that by definition would take longer to administer and score. Using an ultra-brief screener or outcome tool is practical, meaning that it will actually be USED, and is meant to “open the discussion” with patients and alert the provider rather than zero in on the fine points.

Two example instruments that are translated into several languages are the ROS (3-item; available at http://thecoloradocenter.com/outcomes) and the ORS (4-item; available at scottdmiller.com). These both are free, peer-reviewed and validated in major journals, function similarly, and can be considered alternate forms of the same underlying (much longer) instrument on which they are based (the OQ-45.2). The gist of scoring is that when an item score is below about a 6, it should alert the provider to inquire about what might be going on, or “What would need to be different in order for that to be more like an 8 or a 9?” As a conversation starter, these are very efficient 30-60sec tools, assessing whether psychotherapy should be recommended to address ongoing distress. On the ORS and ROS, the average psychotherapy patient at intake scores in the 5-6 range (on average) on these items. People in the community score an average of a 7.

John Corsino DPT

Thank you so much for sharing these. I think their application goes a long way in defining “those at high risk.”

John Corsino DPT

Yes Christine! So many problems in healthcare right now are made worse by the fact that we have to wait for patients to make contact. My favorite analog is a patient with a lifeline device – it’s so much more useful if we require them to check in every day, and do a home visit if they fail to, rather than wait for them to activate.